• Care Home
  • Care home

Victoria Court

Overall: Requires improvement read more about inspection ratings

1 Victoria Park, Weston Super Mare, Somerset, BS23 2HZ (01934) 629392

Provided and run by:
Community Therapeutic Services Limited

All Inspections

24 January 2023

During an inspection looking at part of the service

About the service

Victoria Court is a residential service providing personal care for up to 6 people with learning disabilities, mental health support needs and autistic people. The service consists of an adapted building, which includes individual bedrooms, communal spaces and an accessible outdoor space. At the time of our inspection there were 6 people using the service.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff supported people with their medicines in a way that promoted their independence. People had a choice about their living environment and were able to personalise their rooms. The service gave people care and support in a safe, clean, well equipped, well-furnished and well-maintained environment.

Right Care:

The service had plans and guidance for staff to support people with their individual risks. Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it. The service had enough appropriately skilled staff to meet people’s needs and keep them safe.

Right Culture:

The provider had systems in place to monitor the quality of the service to people. However, we found quality assurance systems were not being completed regularly to ensure quality and potential safety issues were identified and acted upon. People received support from staff who knew them well. The service enabled people and those important to them to work with staff to develop the service. Staff ensured risks of a closed culture were minimised so that people received support based on transparency, respect and inclusivity.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 23 July 2019) and there was a breach of regulation 17. At this inspection we found the provider remained in breach of this regulation. This service has been rated requires improvement for the last two consecutive inspections.

At our last inspection we made recommendations regarding the management of medicines and mental capacity assessments. At this inspection we found the provider had acted on these recommendations and improvements had been made.

Why we inspected

We carried out an unannounced inspection of this service on 4 and 6 June 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Victoria Court on our website at www.cqc.org.uk.

Enforcement

We have identified a repeated breach of Regulation 17 (Good Governance) at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

4 June 2019

During a routine inspection

About the service: Victoria Court provides accommodation and personal care for up to six younger people with learning disabilities, autism and mental health needs. At the time of the inspection five people were living at the service.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

People’s experience of using this service: People were supported in a homely environment and by caring staff. The service was clean and tidy. Recent refurbishment had occurred of the kitchen and hallways.

Care and support were person centred and reflected people’s individual choices and wishes. The service was flexible in meeting peoples changing needs. People were supported to shop and prepare food or meals were provided.

Medicine administration required improvement to ensure best practice guidance was followed. Systems were in place to monitor the quality of the service. However, identified actions had not always been completed. This meant that shortfalls found at this inspection had not been addressed.

Staff spoke positively about the ethos of the service, the induction they received, and the ongoing training provided. Positive feedback was received about the registered manager and their approach to staff and people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, we found mental capacity assessments and best interest decisions were not always regularly reviewed.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

For more details, please see the full report which is on CQC website at www.cqc.org.uk

Rating at last inspection: The last rating for this service was Good (published 30 November 2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Enforcement: We have identified a breach in relation to good governance at this inspection. We have made two recommendations in relation to medicines and following recommended guidance in the review of mental capacity assessments and best interest decisions. Please see the action we have told the provider to take at the end of this report.

Follow up: We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

26 September 2016

During a routine inspection

We inspected this service on the 26 and 27 September 2016. This was an unannounced inspection. At our last inspection in June 2015 we found breaches of legal requirements in relation to, poor and inaccurate records, unsafe recruitment procedures, unsafe laundering of people’s clothes and poor use of personal protective equipment. After the inspection the provider sent us an action plan saying how they would meet these legal requirements and by when. At this inspection we found the provider had made the improvements required.

Victoria Court provides accommodation and personal care for up to six people who do not have nursing needs. At the time of the inspection there were six people living at the home. Victoria court is set over two floors. The ground floor has two bedrooms, along with two communal lounges, the laundry room, a dining area, kitchen and access to the outside patio area. The first floor has four rooms, the manager’s office, a staff sleeping area, and medication room. All bedrooms are en-suite.

At the time of this inspection the registered manager had just left. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People had detailed care plans that were personalised to them. They had risk assessments and support plans that gave staff guidelines to follow. Staff knew people well and were able to demonstrate a sensitive and caring approach when people required staff support. People’s personal evacuation plans had details of what support the person might require in an emergency.

People were supported by staff who had checks completed prior to commencing their employment. People felt safe and staff were able to demonstrate what action they would take should they have concerns to people’s safety. People were supported by staff who received regular supervision and training to ensure they were competent and skilled to meet their individual care needs.

People received their medicines safely and when required by staff who had received training. Although one person required a support plan in place relating to their diabetes care. People were supported by adequate staffing levels and staff supported people in a kind and caring manner. Staff demonstrated they knew people well and felt supported and able to raise any concerns with the management of the home.

People were able to make decisions about the care they received and were enabled to be independent. Changes to people’s care needs were identified and planned with them and their care plans were amended to reflect those changing needs. The service was flexible and people and relatives views were sought so improvements could be made. People were happy with the care and felt able to raise a complaint if they had one. People were able to access the community when they wanted and the provider promoted relationships with friends and family.

The provider had a quality assurance system to monitor the quality and safety of the service. Although it wasn’t always effective at identifying areas for improvement for example, deprivation of liberty safeguarding’s that had expired, areas of improvement to the building and appliances that needing testing.

We have made a recommendation that the provider seeks guidance about effective audits for the home.

18 & 26 June 2015

During a routine inspection

We carried out this unannounced inspection on the 18 and 26 June 2015. At our last inspection in July 2014 we found that the laundry environment was unsafe which posed a risk to infection control at the home. At this inspection we found improvements were still required.

Victoria Court provides accommodation for up to six people who had a learning disability, autism and or mental health needs and who require personal and/or nursing care. At the time of our visit there were six people living at the home. Victoria court is set over two floors. The ground floor has two bedrooms, along with two communal lounges, the laundry room, a dining area, kitchen and access to the outside patio area. The first floor has four rooms, the manager’s office, staff sleeping area, and medication room. All bedrooms are en-suite.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was present during the inspection.

Improvements had been made to ensure people were better protected from the risks of infection. The laundry room had a new floor, skirting boards and tiles. Mops had been replaced with steam cleaners and the extractor fan had been cleaned. There were still some concerns relating to poor use of personal protective equipment and the handling of soiled and contaminated laundry.

Not all staff had received appropriate pre-employment checks before commencement of employment. However, the manager had systems in place which ensured staff did not work on their own with people until their competence was checked. We found these risks were not being managed with an appropriate risk assessment.

Not all risk assessments for keeping people safe were accurate and up to date. One person required their risk assessment to be updated and review dates to be added. The evaluation process in place had failed to identify this shortfall. These risks were reduced because staff knew people well.

People had detailed behaviour support plans in place. Staff knew how to support people well. For example, we saw positive interactions with a member of staff and how they supported someone who became upset with anxiety.

People told us they felt safe and that staff knew them well and were kind and caring. Staff knew about different types of abuse and what they should do if they suspected abuse.

The principles of the The Mental Capacity Act 2005 code of practice including the Deprivation of Liberty Safeguards were being followed and we saw appropriate paperwork in place.

All staff confirmed they felt they received adequate training. Not all staff had received refresher training in relation to safe administration of medicines, Safeguarding adults and The Mental Capacity Act. The manager confirmed actions had been take to address this. There was a good staff induction and we saw new staff received training relating to their role.

People had enough food and drink. There was enough choice and control with their meals including the times that they chose to have their meals. All people we spoke with confirmed they were happy with these arrangements.

Referrals to health care professionals were made for people when required. All people we spoke with were happy with the support they received. One health care professional we spoke with confirmed they were happy with the service.

Staff felt they received enough supervision meetings and were supporting by the manager. There were daily hand over meetings and staff there had been a recent staff meeting.

Staff interacted with people in a kind, caring and polite manner. People were happy with the care that they received.

Care plans included peoples life histories and staff we spoke with knew people well. People confirmed how they made their own choices and care plans confirmed their wishes.

People were supported with their choices, for example, when they wished to get up in the morning and access the community.

People had support to follow interests and activities that were important to them.

Care plans contained various pre assessments and important information relating to people. Care provided was person centred.

People had regular reviews and key workers were responsible for co-ordinating and liaising with people when their needs changed.

There was a complaints policy in place along with an easy read version but there was no overview of actions taken to resolve complaints. Following our inspection, the manager sent us a copy of the plans they were going to implement to address this.

We found at times there were duplicate records that were out of date. This included records relating to pen portraits, personal evacuation plans, fire plans and risk assessments.

Not all areas of the health and safety audit identified areas of concern found on the inspection. This included staff practice relating to personal protective equipment, handling of soiled and contaminated laundry and one area of the home that had paper peeling off the wall and evidence of damp coming through.

There was a system for logging all incidents and accidents in the home and we saw that these were reviewed and actions taken when required.

There was a system in place to ensure people and relatives were sent an annual survey. Most people were happy with living at the home. We found there was no overall analysis of actions taken following the comments received about the home.

We found three breach's of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

1 July 2014

During a routine inspection

We considered our inspection findings to answer questions we always ask; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you would like to see the evidence supporting our summary please read the full report.

Is the service safe?

People were supported by staff who had received training in safeguarding adults. Staff we spoke with confirmed they knew what actions to take if they witnessed or saw abuse and how they would report it.

We saw the home had undertaken a range of risk assessments for each person. Some of these risk assessments had just been completed and required a date and signature. We found one person did not have a risk assessment relating to one area of risk in their life. We fed this back to the registered manager. They confirmed they would undertake this risk assessment and would sign and dating those that required it.

We observed the laundry environment was unsafe and posed a risk to infection control. We saw that the laundry room required tiles and a new skirting board. There was a broken unsealed floor that had red disposable soiled linen bags on top of it. We saw the home was not ensuring the safe procedure for soiled laundry was followed as dirty laundry was stacked in baskets on top of each other. There was also an extractor fan covered in dust and dirt. A compliance action has been sent in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of Deprivation of Liberty Safeguards which applies to care homes. There were no current applications in place at the time of this inspection however we have highlighted a restrictive practice that the provider needs to review.

Is the service effective?

We saw staff provide positive interactions with people. They spoke with people in a polite and calm manner. People spoke positively about certain staff. Relatives spoke positively regarding their experience of the service.

We saw person centred care plans that identified people's individual goals. Where people could make decisions this was recorded in their care plan. We saw the home had undertaken best interest decisions and consulted family, relatives and significant others into decisions that were being made. The provider might wish to note that although there was evidence that a best interest decision was made, there was no evidence that a formal mental capacity assessment under the Mental Capacity Act 2005 had been undertaken.

We saw people's care had detailed guidelines for staff to follow. Staff confirmed these guidelines. This meant that people received care and support that met their individual care needs.

Is the service caring?

Staff we spoke with told us how they supported and cared for people with varying levels of communication needs. They said 'I use hand signals and picture exchange communication cards as well as visual aids'. They also told us what choices they gave people, 'I offer choice about activities and planning the meals'. We spoke with another member of staff who told us 'I use picture exchange communication cards with X, and offer visual items such as a hot drink or cold one'. They also confirmed how they would adapt their communication to suit the individual, 'I give basic communication to X so that I don't over load them with too much information'. This meant that staff were skilled in using different communication techniques in order to engage with people, this enabled staff to provide appropriate support.

Is the service responsive?

People had access to daily and outside activities. They could choose what activities they wanted to undertake. One person said 'I am going to the dentist today, I made the appointment myself'.

Records confirmed that people's personal preferences, interests and their goals and wishes were known.

Is the service well-led?

Relatives we spoke with said how happy they were with the service. They told us 'I am very very satisfied'. They confirmed 'staff care exceedingly well for X'. Another relative told us 'It's better now than what it was'.

Two people we spoke with told us how they have problems accessing the washing machine as it is always busy. They told us 'I can't always use the washing machine as it's busy' and 'the washing machine is always in use'. We fed this back to the manager for them to action.

We saw staff attended a hand over meeting twice a day. This was recorded on a wipe board in the office so staff could see the activities and what was important to people that day.

We reviewed the homes audit system for infection control and buildings maintenance. This audit was undertaken once a month. The audit failed to identify some areas of risk relating to infection control and buildings maintenance. We fed this back to the registered manager and owner. The provider might wish to note that this audit did not robustly identify some areas of infection control and buildings maintenance so that all concerns can be addressed.

The home had taken action to seek views from people and relatives by sending out recent satisfaction questionnaires.

There was detailed analysis of accidents and incidents and these were discussed in clinical meetings.

The provider had two managers who are registered with the Care Quality Commission at this location. They confirmed on our inspection that there is only one registered manager responsible for Victoria Court, we have asked the provider to contact the manager who had left their employ and ask them to de register for this location. The report will therefore still include the names of the two registered managers until we have received an application that the former manager has deregistered.

We have asked the provider to submit a new statement of purpose to reflect the management changes.

22 November 2013

During a routine inspection

People who used the service appeared very comfortable around the home and were very welcoming towards us. We spoke with four people and heard about their experience of the service. We saw there were good interactions between people and staff, often sharing banter and jokes. The atmosphere in the home was relaxed and inclusive; we saw that people were making choices about their daily activity.

We were told the service was responsive, one person said 'they are pretty good and work around my needs.' We observed that staff explained and discussed with people their choices and any actions needed to support activity. For example, checking they had all they needed when going out.

We saw each person had a plan which described the support they required; in this we read people's choices were recorded and implemented. We saw there were risk assessments in place for some people which promoted well-being and prevented crisis.

Staff we spoke with were positive about working in the home and the contribution they made to people having fulfilling lives. We heard they felt well led and supported in their role by the home's management.

The environment was bright and communal areas were comfortably furnished. The home was in the process of being redecorated.

People were aware of the complaint system; this was provided in a format that met their needs.

We found people were not protected from the risk of infection because appropriate guidance had not been fully implemented.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

13 March 2013

During a routine inspection

On the day of our inspection we were told that the registered manager had left the home and was working at another of the provider's services. We were told that the home had a new manager who had been in post since January. The manager told us that they were currently applying to be the registered manager of the home.

During our inspection we spoke with four of the six people who lived at the service. All of the people we spoke with told us that they liked living at the home and that the staff involved them in their care and support.

People told us they were encouraged to be independent and were involved in planning their activities and how they spent their time.

People were supported to establish and maintain relationships with their families and friends.

Care and support delivered by the home was tailored to people's individual needs.

We found that medicines were managed appropriately and safely at the home. Some people in the home were supported to manage their own medicines safely.

The staffing levels at the home were found to be appropriate for the needs of the people living at the home.

People were supported to make complaints and could be confident that these would be listened to and dealt with appropriately.

30 September 2011

During a routine inspection

We visited Victoria Court on 30 September 2011. People who live at Victoria Court have a range of mental health needs, including learning disabilities and personality disorders. We met with five of the six people who live at the home. The other person was out in the community. We talked with the five people we met and asked them about living at Victoria Court.

We also met and talked with members of the staffing team at the service and met briefly with some members of the senior management team during our introduction.

People who live at the service have their own rooms. The facilities in the rooms reflect the person's choices, level of independence, and developmental possibilities. We visited the room of one person who had their own kitchen, which had recently been installed, and promoted their independence. Another person is hoping to have their room developed in a similar way to provide them with more independence and encourage new skills.

People who use the service said that they felt safe living at Victoria Court. They said that members of staff treated them with respect and knew them well. One person said that some of the newer members of staff did not yet know enough about them, but agreed that it takes time to build a relationship of trust. People told us that they had plenty of daily activities and took part in those things that they wanted to do. We were also told that people spend time in the local community and can be supported by members of staff to do this.